DDH Surgery: Understanding Procedures, Recovery, and Long-Term Outlook

What is DDH Surgery?

DDH surgery refers to a range of surgical procedures performed to correct developmental dysplasia of the hip (DDH), a condition where the hip joint has not formed properly. These interventions aim to realign the hip joint, ensuring proper development and function, particularly when non-surgical methods are insufficient or unsuccessful.

Understanding Developmental Dysplasia of the Hip (DDH)

Developmental Dysplasia of the Hip (DDH), previously known as congenital dislocation of the hip, is a condition affecting the hip joint's formation. It occurs when the ball (femoral head) and socket (acetabulum) of the hip joint do not fit together correctly. This can range from mild instability to complete dislocation of the femoral head from the acetabulum.

• Anatomy Affected: The hip is a ball-and-socket joint. In DDH, the acetabulum may be too shallow or poorly formed, preventing the femoral head from seating deeply and securely. This can lead to instability, subluxation (partial dislocation), or complete dislocation.
• Causes and Risk Factors: While the exact cause is often unknown, several factors increase the risk, including:
  • Breech presentation: Babies born feet-first.
  • Female gender: Girls are more commonly affected.
  • First-born status.
  • Family history of DDH.
  • Oligohydramnios: Low amniotic fluid during pregnancy.
  • Post-natal swaddling practices that restrict hip movement.
• Symptoms and Diagnosis: DDH is often asymptomatic in infants, making early screening crucial. Signs can include:
  • Asymmetrical leg length.
  • Uneven skin folds on the thighs.
  • Limited range of motion in one hip.
  • Clicking or popping sounds during hip examination (though not always indicative of DDH).
  • In older children, a limp or waddling gait. Diagnosis typically involves physical examination, ultrasound (for infants under 6 months), and X-rays (for infants over 6 months and older children).

When is Surgery for DDH Necessary?

The primary goal of DDH treatment is to achieve and maintain a stable, concentric reduction of the femoral head within the acetabulum, promoting normal hip development. Treatment strategies vary based on the child's age and the severity of the dysplasia.

• Non-Surgical Treatments:
  • Pavlik Harness: For infants up to 6 months of age, this soft brace holds the hips in a flexed and abducted position, encouraging the femoral head to seat properly and stimulate acetabular development.
  • Abduction Bracing/Casting: For slightly older infants (6-18 months) or when the Pavlik harness is unsuccessful, more rigid bracing or casting (e.g., a spica cast) may be used after a closed reduction.
• Indications for Surgical Intervention: Surgery becomes necessary when:
  • Non-surgical methods fail to achieve or maintain a stable reduction of the hip.
  • The child is diagnosed at an older age (typically over 18 months), where non-surgical methods are less effective due to more established anatomical deformities.
  • The hip dysplasia is severe, involving significant bony abnormalities of the acetabulum or femur.

Types of DDH Surgical Procedures

DDH surgery aims to either reduce (put back into place) the dislocated hip, reshape the bones of the hip joint to create a more stable socket, or both.

• Closed Reduction:
  • Performed under general anesthesia, where the surgeon manually manipulates the femoral head back into the acetabulum without making an incision.
  • Often followed by application of a spica cast to maintain the reduction.
  • Typically used for infants and young children (up to 18-24 months) when non-surgical methods have failed but the hip can still be reduced non-invasively.
• Open Reduction:
  • Involves a surgical incision to directly visualize the hip joint.
  • Allows the surgeon to remove any obstructing tissues (e.g., inverted labrum, hypertrophied ligamentum teres, pulvinar) that prevent a stable closed reduction.
  • The femoral head is then manually placed into the acetabulum under direct vision.
  • Often required for older children, cases where closed reduction failed, or when significant soft tissue impediments exist.
  • Followed by a spica cast for several weeks to months.
• Pelvic Osteotomies:
  • Procedures that involve cutting and reshaping the pelvic bone (acetabulum) to improve its coverage of the femoral head, creating a deeper and more stable socket.
  • Common types include:
    • Salter Osteotomy: Repositions the entire acetabulum.
    • Dega Osteotomy: Redirects the superior and anterior portions of the acetabulum.
    • Pemberton Osteotomy: Involves an incision around the acetabulum to redirect it inferiorly and anteriorly.
    • Triple Innominate Osteotomy: Separates three bones of the pelvis (ilium, ischium, pubis) to allow for significant repositioning of the acetabulum.
  • These are often performed in conjunction with an open reduction, particularly in children over 18 months to 2 years of age, or when significant acetabular dysplasia persists after reduction.
• Femoral Osteotomies:
  • Involve cutting and reshaping the upper part of the femur (thigh bone) to improve the alignment of the femoral head within the acetabulum.
  • May be performed to correct excessive anteversion (forward twist) of the femur, or to shorten the femur to reduce pressure on the hip joint after reduction, especially in older children.
  • Often performed in combination with pelvic osteotomies.
• Combined Procedures: It is common for surgeons to perform a combination of open reduction, pelvic osteotomy, and/or femoral osteotomy, depending on the specific anatomical deformities and the child's age.

The Surgical Process: What to Expect

The surgical journey for DDH involves careful planning, the procedure itself, and a structured recovery.

• Pre-Operative Preparation:
  • Comprehensive Assessment: Includes detailed imaging (X-rays, MRI, CT scans) to precisely map the hip's anatomy.
  • Medical Clearance: Ensures the child is healthy enough for surgery and anesthesia.
  • Patient and Family Education: Surgeons and nurses provide thorough information about the procedure, potential risks, and post-operative care.
• The Surgery Itself:
  • Performed under general anesthesia.
  • The duration varies significantly depending on the complexity of the procedure (e.g., closed reduction vs. combined osteotomies).
  • Surgeons use fluoroscopy (real-time X-ray imaging) during the procedure to confirm correct placement and alignment.
• Post-Operative Care: Initial Recovery:
  • Pain Management: Administered via IV or oral medications.
  • Immobilization: Most DDH surgeries are followed by the application of a spica cast, which extends from the chest to the ankle on the affected side (or both legs), keeping the hips in a stable position. This cast is crucial for allowing the bones and soft tissues to heal in the corrected position.
  • Hospital Stay: Typically ranges from a few days to a week, depending on the procedure and the child's recovery.
  • Cast Care: Parents receive detailed instructions on how to care for the spica cast, including hygiene, diapering, and positioning to prevent skin breakdown.

Rehabilitation and Long-Term Outlook

Rehabilitation is a critical component of DDH surgery recovery, focusing on restoring mobility, strength, and function.

• Physical Therapy and Rehabilitation:
  • Cast Removal: After several weeks or months (typically 6-12 weeks), the spica cast is removed.
  • Gradual Mobilization: Initial focus is on regaining hip range of motion, which will be stiff and limited after prolonged immobilization.
  • Strength Training: Progressive exercises target the hip abductors, adductors, flexors, and extensors, as well as core stability, to support the newly aligned joint.
  • Gait Training: Re-learning proper walking patterns and restoring symmetrical movement is essential.
  • Activity Progression: Gradually increasing weight-bearing activities and returning to age-appropriate play and sports. This process can take several months to a year or more.
• Potential Complications: While generally safe and effective, potential complications can include:
  • Avascular Necrosis (AVN): Damage to the blood supply of the femoral head, which can lead to bone death and collapse. This is a serious but relatively rare complication.
  • Re-dislocation or Subluxation: The hip moving out of place again.
  • Nerve Damage: Temporary or permanent.
  • Infection: At the surgical site.
  • Leg Length Discrepancy: May occur if bone growth is affected.
  • Stiffness or Limited Range of Motion: May require further therapy or intervention.
• Long-Term Prognosis and Activity Levels:
  • With successful surgery and rehabilitation, most individuals achieve a good outcome, with a stable, functional hip joint.
  • Regular follow-up appointments are necessary, often until skeletal maturity, to monitor hip development and address any late-onset issues.
  • Many individuals can return to a full range of physical activities, including sports. However, long-term monitoring for the development of osteoarthritis later in life is often recommended, as even successfully treated hips may have a slightly increased risk.

Conclusion

DDH surgery is a vital intervention for correcting developmental dysplasia of the hip when conservative treatments are insufficient. By understanding the underlying condition, the various surgical approaches, the recovery process, and the importance of dedicated rehabilitation, patients and their families can navigate this journey with informed confidence. Early diagnosis and a multidisciplinary approach involving orthopedic surgeons, physical therapists, and other healthcare professionals are key to optimizing long-term hip health and function.